Skin Integrity & Wound Care

Question 1

what are some functions of the skin?

Answer 1

protection
body temperature
psychosocial
sensation
vitamin d production
immunologic
absorption
elimination

Question 2

what are some factors effecting the skin?

Answer 2

unbroken/healthy skin and intact mucous membranes (defense)

resistance to injury affected by age and illness

adequate nourished and hydrated tissue cells are resistance to injury

adequate circulation is necessary to cell life

Question 3

what are some developmental considerations for the skin?

Answer 3

infants have weak mucous membranes hat are easily injured

kids younger than 2 have thinner and weaker skin than adults

the structure of the skin changes with age leading to thin easily damaged skin

circulation and collagen formation are impaired leading the decreased elasticity

Question 4

name the different types of wounds

Answer 4

intentional or unintentional
open or closed
acute or chronic
partial thickness, full-thickness, and complex

Question 5

define: open and closed wounds

Answer 5

open: complete break of epithelial protective surface (abrasions, lacerations, de-gloving etc.)
closed: skin is intact with underlying tissue damage (contusions, bruises, hematomas)

Question 6

define: acute and chronic wounds

Answer 6

acute: they pass through the normal healing process slowly and consist of: lacerations, cuts, abrasions, punctures etc.
chronic: any wound >3 months old consisting of: anything failing to undergo the normal healing process

Question 7

what are the phases of wound healing?

Answer 7

hemostasis
inflammatory
proliferation
maturation

Question 8

what is hemostasis?

Answer 8

it occurs immediately post initial injury and involves blood vessels which constrict and begin clotting.
exudate is formed causing swelling and pain.
platelets stimulate other cells to migrate to the site of injury for further phases of healing

Question 9

what is the inflammatory phase?

Answer 9

this occurs after hemostasis and lasts 2-3 days. WBC’s (leukocytes and macrophages) move to the wound site to ingest the remaining debris and to attract fibroblasts to fill in the wound

Question 10

what is the proliferation phase?

Answer 10

it lasts for several weeks and is when new tissue is built to fill in the wound via the fibroblasts. capillaries grow across the wound and a thin layer of epithelial cells form. granulation tissue forms the foundation for scar tissue.

Question 11

what are some local factors affecting wound healing?

Answer 11

pressure
desiccation
maceration
trauma
edema
infection
excessive bleeding
necrosis 
presence of biofilms

Question 12

what are the types of wound complications?

Answer 12

infections
hemorrhage
dehiscence and evisceration
fistula formation

Question 13

what are the psychological effects of wounds?

Answer 13

pain
anxiety
fear
impact on ADLs
change in body image

Question 14

what are the factors leading to pressure injury development?

Answer 14

aging skin
chronic illness
immobility
malnutrition
fecal and urinary incontinence
altered level of consciousness
spinal cord and brain injuries
neuromuscular disorders

Question 15

what are the 2 mechanisms in pressure injury development?

Answer 15

external pressure compressing the blood vessels

friction or shearing forces that tear/injure blood vessels

Question 16

what are the stages of a pressure injury?

Answer 16

stage 1: non-blanchable erythema on intact skin
stage 2: partial-thickness skin loss with exposed dermis
stage 3: full-thickness skin loss, doesn’t involve under lying tissues/fascia
stage 4: full-thickness skin and tissue loss

un-stagable: obscured full-thickness skin and tissue loss
deep tissue pressure injury: persistent, non-blanchable deep red/maroon/purple discoloration

Question 17

how do you measure a pressure injury?

Answer 17

obtain size of wound
depth of the wound
look for presence or undermining, tunneling or sinus tract

use q-tips, rulers and photos for possible developmental changes

Question 18

explain: how to clean a pressure injury/wound

Answer 18

clean wound with every dressing change
use a new gauze for each wipe, cleaning from top-bottom or from center-outside
use 0.9% NSL to irrigate and clean site
once wound is cleaned, dry with gauze in same manner above
document and report and drainage or necrotic tissue

Question 19

what are the different types of wound drainage?

Answer 19

serous: clear, serous portion of blood from membranes
sanguineous: containing or mixed with blood
serosanguineous: mixture of RBCs and serum
purulent: comprised of WBCs, dead tissues, debris and dead/live bacteria

Question 20

assessing a wound includes

Answer 20

inspection: sight and smell
palpation: appearance, drainage, and pain

sutures, drains or tubes and any manifestation of complications

Question 21

what are the indicators for presence of an infection

Answer 21

swelling
deep red colored
radiating warmth/ hot to the touch
drainage is increased and possibly purulent
foul odor may be present
wound edges may be seperated with dehiscence present

Question 22

what is the purpose of wound dressings?

Answer 22

provide physical, psychological and aesthetic comfort
prevent, eliminate or control infections
absorb drainage
maintain moisture balance of wound
protect the wound from further injury
protect the surrounding tissues
stimulate and/or optimize healing response
consider ease of use and cost-effectiveness
debride os appropriate

Question 23

what are the types of wound dressings?

Answer 23

telfa pads
gauze dressings
transparent dressings (tegaderm)

Question 24

what are the different types of bandages?

Answer 24

roller bandages
circular turn
spiral turn
figure-of-eight turn

Question 25

what are the different types of binders?

Answer 25

slings abdominal binders chest binders t-binders

Question 26

what are the 2 types of drainage systems and their drains?

Answer 26

open systems: penrose drain closed systems: jackson-pratt drain, hemovac drain, and wound vac

Question 27

what are penrose drains?

Answer 27

they are passive drainage tubes that are soft, flexible, and made of rubber. they are used as surgical drains to prevent buildup of fluid in the surgical site.

Question 28

what are jackson-pratt drains?

Answer 28

they are a tube attached to a bulb that uses suction to pull continuous fluids from within the surgical site/cavity. document the color and characteristics of fluid. emptied every 4-6 hours generally. increases in bright red drainage indicates possible internal bleeds.

Question 29

what are the topics for at home health care teaching?

Answer 29

``` supplies required infection prevention wound healing and what to expect appearance of the skin/recent chages activity/mobility nutrition pain elimination ```

Question 30

what are nursing assessments for pressure injuries?

Answer 30

``` risk assessments mobility level nutritional status moisture present or incontinence appearance of preexisting pressure injuries pain assessments ```

Question 31

what are the factors affecting responsiveness to hot or cold treatments?

Answer 31

method and duration of application temperature of the hot or cold applications patients age and physical condition amount of body surface covered by application

Question 32

what are the effects of applying heat to an injury?

Answer 32

``` dilates peripheral blood vessels increases tissue metabolism reduces blood viscosity and increases permeability reduces muscle tension helps relieve pain ```

Question 33

what are the effects of applying cold to an injury?

Answer 33

constricts peripheral blood vessels reduces muscle spasms promotes comfort

Question 34

what devices can be used to apply heat therapy?

Answer 34

``` hot water bags electric blankets aquathermia pads hot packs warm/moist compresses sitz baths warm soaks ```

Question 35

what devices can be used to apply cold therapy?

Answer 35

ice bags cold packs hypothermia blankets cold compresses to apply moist cold 20 mins on and 20 mins off use a barrier between skin and cold item

Question 36

what are some causes of skin alterations?

Answer 36

being very thin or obese predisposes one to skin injury excessive perspiration during an illness predisposes to skin break down jaundice causes yellow itchy skin diseases of the skin (eczema and psoriasis) that can cause lesions

Question 37

what are the 3-types of wound healing?

Answer 37

first-intention: an open wound is closed surgically with sutures or staples as soon as possible second-intention: would is kept clean and open to allow tissue to repair self and close on own third-intention: the wound is left open to allow infection to clear before later being closed surgically with sutures of staples

Question 38

what is the maturation phase of healing?

Answer 38

it is the final stage which starts 3 weeks post initial injury and can continue healing for months or years collagen is remodeled with new collagen being deposited scar becomes a flat, thing white line

Question 39

what are hemovac drains vs wound vac drains?

Answer 39

hemovac: tube with holes inserted in the wound with an accordion press that creates suction vac: a foam dressing inside the wound, covered by a transparent file with suction via a vacuum machine that physically pulls out drainage to improve granulation and wound healing